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Going off antidepressants

If not handled carefully, coming off your medication can cause disturbing symptoms and set you up for a relapse of depression.

About 10% of women ages 18 and over take antidepressants. As many of us know, these medications can be a godsend when depression has robbed life of its joy and made it hard to muster the energy and concentration to complete everyday tasks. But as you begin to feel better and want to move on, how long should you keep taking the pills?

If you're doing well on antidepressants and not complaining of too many side effects, many physicians will renew the prescription indefinitely — figuring that it offers a hedge against a relapse of depression. But side effects that you may have been willing to put up with initially — sexual side effects (decreased desire and difficulty having an orgasm), headache, insomnia, drowsiness, vivid dreaming, or just not feeling like yourself — can become less acceptable over time, especially if you think you no longer need the pills.

The decision to go off antidepressants should be considered thoughtfully and made with the support of your physician or therapist to make sure you're not stopping prematurely, risking a recurrence of depression. Once you decide to quit, you and your physician should take steps to minimize or avoid the discontinuation symptoms that can occur if such medications are withdrawn too quickly.

Why discontinuation symptoms?

Antidepressants work by altering the levels of neurotransmitters — chemical messengers that attach to receptors on neurons (nerve cells) throughout the body and influence their activity. Neurons eventually adapt to the current level of neurotransmitters, and symptoms that range from mild to distressing may arise if the level changes too much too fast — for example, because you've suddenly stopped taking your antidepressant. They're generally not medically dangerous but may be uncomfortable.

Among the newer antidepressants, those that influence the serotonin system — selective serotonin reuptake inhibitors (SSRIs, now commonly known as SRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) — are associated with a number of withdrawal symptoms, often called antidepressant or SRI discontinuation syndrome. Stopping antidepressants such as bupropion (Wellbutrin) that do not affect serotonin systems — dopamine and norepinephrine reuptake inhibitors — seems less troublesome over all, although some patients develop extreme irritability.

Having discontinuation symptoms doesn't mean you're addicted to your antidepressant. A person who is addicted craves the drug and often needs increasingly higher doses. Few people who take antidepressants develop a craving or feel a need to increase the dose. (Sometimes an SRI will stop working — a phenomenon called "Prozac poop-out" — which may necessitate increasing the dose or adding another drug.)

Discontinuation symptoms can look like depression

Discontinuation symptoms can include anxiety and depression. Since these may be the reason you were prescribed antidepressants in the first place, their reappearance may suggest that you're having a relapse and need ongoing treatment. Here's how to distinguish discontinuation symptoms from relapse:

Discontinuation symptoms emerge within days to weeks of stopping the medication or lowering the dose, whereas relapse symptoms develop later and more gradually.

Discontinuation symptoms often include physical complaints that aren't commonly found in depression, such as dizziness, flulike symptoms, and abnormal sensations.

Discontinuation symptoms disappear quickly if you take a dose of the antidepressant, while drug treatment of depression itself takes weeks to work.

Discontinuation symptoms resolve as the body readjusts, while recurrent depression continues and may get worse.

"If symptoms last more than a month and are worsening, it's worth considering whether you're having a relapse of depression," says George I. Papakostas, M.D., associate professor of psychiatry at Harvard Medical School.

A range of symptoms

Neurotransmitters act throughout the body, and you may experience physical as well as mental effects when you stop taking antidepressants or lower the dose too fast. Common complaints include the following:

Digestive. You may have nausea, vomiting, cramps, diarrhea, or loss of appetite.

Sleep changes. You may have trouble sleeping and unusual dreams or nightmares.

Balance. You may become dizzy or lightheaded or feel like you don't quite have your "sea legs" when walking.

Control of movements. You may experience tremors, restless legs, uneven gait, and difficulty coordinating speech and chewing movements.

Unwanted feelings. You may have mood swings or feel agitated, anxious, manic, depressed, irritable, or confused — even paranoid or suicidal.

Strange sensations. You may have pain or numbness; you may become hypersensitive to sound or sense a ringing in your ears; you may experience "brain-zaps" — a feeling that resembles an electric shock to your head — or a sensation that some people describe as "brain shivers."

As dire as some of these symptoms may sound, you shouldn't let them discourage you if you want to go off your antidepressant. According to a 2004 consensus statement by a panel of physicians, many of the symptoms of SRI discontinuation syndrome can be minimized or prevented by gradually lowering, or tapering, the dose over weeks to months, sometimes substituting longer-acting drugs such as fluoxetine (Prozac) for shorter-acting medications. The antidepressants most likely to cause troublesome symptoms are those that have a short half-life — that is, they break down and leave the body quickly. (See the chart "Antidepressant drugs and their half-lives.") Examples include venlafaxine (Effexor), sertraline (Zoloft), paroxetine (Paxil), and citalopram (Celexa). Extended-release versions of these drugs enter the body more slowly but leave it just as fast. Antidepressants with a longer half-life, chiefly fluoxetine, cause fewer problems on discontinuation.

Besides easing the transition, tapering the dose decreases the risk that depression will recur. In a Harvard Medical School study published in the American Journal of Psychiatry in August 2010, nearly 400 patients (two-thirds of them women) were followed for more than a year after they stopped taking antidepressants prescribed for mood and anxiety disorders. Participants who discontinued rapidly (over one to seven days) were more likely to relapse within a few months than those who reduced the dose gradually over two or more weeks.

Antidepressant drugs and their half-lives*

Drug

Half out of body in

99% out of body in

Serotonin reuptake inhibitors

paroxetine (Paxil)

24 hours

4.4 days

sertraline (Zoloft)

26 hours

5.4 days

escitalopram (Lexapro)

27 to 32 hours

6.1 days

citalopram (Celexa)

36 hours

7.3 days

fluoxetine (Prozac)

Four to six days

25 days

Serotonin and norepinephrine reuptake inhibitors

venlafaxine (Effexor)

5 hours

1 day

duloxetine (Cymbalta)

12 hours

2.5 days

desvenlafaxine (Pristiq)

12 hours

2.5 days

Dopamine and norepinephrine reuptake inhibitor

bupropion (Wellbutrin)

21 hours

4.4 days

*Discontinuation symptoms typically start when 90% or more of the drug has left your system.

Slow and steady

If you're thinking about stopping antidepressants, you should go step-by-step, and consider the following:

Take your time. You may be tempted to stop taking antidepressants as soon as your symptoms ease, but depression can return if you quit too soon. Clinicians generally recommend staying on the medication for six to nine months before considering going off it. If you've had three or more recurrences of depression, make that at least two years.

Talk to your clinician about the benefits and risks of antidepressants in your particular situation, and work with her or him in deciding whether (and when) to stop using them. Before discontinuing, you should feel confident that you're functioning well, that your life circumstances are stable, and that you can cope with any negative thoughts that might emerge. Don't try to quit while you're under stress or undergoing a significant change in your life, such as a new job or an illness.

Make a plan. Going off an antidepressant usually involves reducing your dose in increments, allowing two to six weeks between dose reductions. Your clinician can instruct you in tapering your dose and prescribe the appropriate dosage pills for making the change. The schedule will depend on which antidepressant you're taking, how long you've been on it, your current dose, and any symptoms you had during previous medication changes. (Sample tapering plans are available in the books listed in "Selected resources" and at www.health.harvard.edu/women.) It's also a good idea to keep a "mood calendar" on which you record your mood (on a scale of one to 10) on a daily basis.

Consider psychotherapy. Fewer than 20% of people on antidepressants undergo psychotherapy, although it's often important in recovering from depression and avoiding recurrence. In a meta-analysis of controlled studies, investigators at Harvard Medical School and other universities found that people who undergo psychotherapy while discontinuing an antidepressant are less likely to have a relapse.

Stay active. Bolster your internal resources with good nutrition, stress-reduction techniques, regular sleep — and especially physical activity. Exercise has a powerful antidepressant effect. It's been shown that people are far less likely to relapse after recovering from depression if they exercise three times a week or more. Exercise makes serotonin more available for binding to receptor sites on nerve cells, so it can compensate for changes in serotonin levels as you taper off SRIs and other medications that target the serotonin system.

Seek support. Stay in touch with your clinician as you go through the process. Let her or him know about any physical or emotional symptoms that could be related to discontinuation. If the symptoms are mild, you'll probably be reassured that they're just temporary, the result of the medication clearing your system. (A short course of a non-antidepressant medication such as an antihistamine, anti-anxiety medication, or sleeping aid can sometimes ease these symptoms.) If symptoms are severe, you might need to go back to a previous dose and reduce the levels more slowly. If you're taking an SRI with a short half-life, switching to a longer-acting drug like fluoxetine may help.

You may want to involve a relative or close friend in your planning. If people around you realize that you're discontinuing antidepressants and may occasionally be irritable or tearful, they'll be less likely to take it personally. A close friend or family member may also be able to recognize signs of recurring depression that you might not perceive.

Complete the taper. By the time you stop taking the medication, your dose will be tiny. (You may already have been cutting your pills in half or using a liquid formula to achieve progressively smaller doses.) Some psychiatrists prescribe a single 20-milligram tablet of fluoxetine the day after the last dose of a shorter-acting antidepressant in order to ease its final washout from the body, although this approach hasn't been tested in a clinical trial.

Check in with your clinician one month after you've stopped the medication altogether. At this follow-up appointment, she or he will check to make sure discontinuation symptoms have eased and there are no signs of returning depression. Ongoing monthly check-ins may be advised.